Every finding on record at Totally Kids Rehabilitation Hospital - D/P SNF

Based on interview and record review, the facility failed to ensure the arbitration agreements (a private way to settle a legal disagreement outside of a traditional courtroom) provided with the selection of a venue convenient to facility and resident (both parties) for three of three sampled residents (Residents 27, 47, and 51).This failure had the potential to limit Residents' choices and access to a fair arbitration process and impede oversight of dispute resolution outcomes. Findings:1. During a review of Resident 27's admission Record (a document that contains demographic and clinical data) and History and Physical (H&P- a document that contains resident's medical history and a hands-on checkup [physical exam]) , the admission Record and H&P indicated, Resident 27 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure (long term condition when lungs cannot adequately exchange oxygen and carbon dioxide), deletion of chromosome 1p36 ( when a small piece is missing from the tip of the short arm of chromosome 1 [chromosome - a thread like structure that act as a storage unit for genetic information]), and Tetralogy of Fallot (a heart defect involving four structural abnormalities that are present at birth).2. During a review of Resident 47's H&P, the H&P indicated Resident 47 was admitted to the facility on [DATE], with diagnoses which included chronic lung disease (long term lung conditions that obstruct airways, destroy lung tissue, or impair breathing), recurrent pneumonias (multiple, separate episodes of one or both lungs infection), and gross developmental delay (significant delay in two or more developmental areas).3. During a review of Resident 51's admission Record and H&P, the admission Record and H&P indicated, Resident 51 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, cerebral palsy (permanent disorder that affect movement, muscle tone, and posture caused by damage to the developing brain), and spastic quadriplegia (jerky movements of the muscle with loss of function affecting both arms and legs).During a concurrent interview and record review on April 16, 2026, at 9:00 AM, with the Director of Case Management (CM2), Resident 27's arbitration agreement titled, Arbitration of Medical Malpractice Disputes, signed on May 20, 2025, the binding arbitration agreement did not provide for the selection of a venue that is convenient to both parties.A continuous interview and record review with CM2, Resident 47's arbitration agreement titled, Arbitration of Medical Malpractice Disputes, signed on May 7, 2019, the binding arbitration agreement did not provide for the selection of a venue that is convenient to both parties.A continuous interview and record review with CM2, Resident 51's arbitration agreement titled, Arbitration of Medical Malpractice Disputes, signed on December 2, 2025, the binding arbitration agreement does not provide for the selection of a venue that is convenient to both parties.CM2 verified Residents 27, 47, and 51 binding arbitration agreements. CM2 confirmed and stated the binding Arbitration agreements for all three residents did not have information regarding the selection of venues that is convenient to both parties. CM 2 further stated there should have been.During an interview on April16, 2026, at 3:41 PM, with the Administrator (ADMIN), the ADMIN stated the Arbitration agreement form does not provide for the selection of a venue that is convenient to both parties. The ADMIN further stated they don't have a policy and procedure (P&P) for arbitration agreement.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) assessments were accurately coded to reflect the residents' status, care, and services in active diagnoses under Section I for four (4) of 20 residents (Residents 1,19, 20, and 23).This failure had the potential to cause inaccuracy in identifying Resident 1, 19, 20, and 23's care and support needs.Findings: 1. During a review of Resident 1's admission Record (a document that contains demographic and clinical data) and History and Physical (H&P- a document that contains resident's medical history and a hands-on checkup [physical exam]), the admission Record and H&P indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included traumatic brain injury (disruption of normal brain function caused by an outside force), left foot fracture (broken bone) and right big toe fracture. During a concurrent interview and record review on April 13, 2026, at 3:56 PM, with Case Manager Nurse (CM1), Resident 1's MDS Quarterly Assessment (an assessment for a resident that must be completed every 92 days following the previous assessment), dated March 3, 2026, was reviewed. The MDS Quarterly Assessment under Section I titled Active Diagnoses. Infections. 12400. Viral Hepatitis (e.g., Hepatitis A, B, C, D, and E- liver infection caused by different viruses) was checked which indicated that Resident 1 had viral hepatitis. CM1 stated the Viral Hepatitis was checked by mistake since Resident 1 does not have Viral Hepatitis. CM1 further stated the MDS was coded incorrectly. During a concurrent interview and record review on April 16, 2026, at 2:15 PM, with CM1, Resident 1's MDS Quarterly Assessment, dated March 3, 2026, was reviewed. The MDS Quarterly Assessment under section I title Active Diagnoses. Neurological [affecting brain and nervous system] . 15400. Seizure Disorder or Epilepsy (a sudden uncontrolled episode of abnormal electrical activity in the brain, often causing involuntary, rapid, and uncontrollable shaking or spasming of the body, staring spells, or loss of consciousness) was left blank which indicated that Resident 1 did not have a seizure disorder. CM 1 verified and stated the seizure was not documented correctly since Resident 1 had seizure disorder. 2. During a review of Resident 19's admission Record and H&P, the admission Record and H&P indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included anoxic brain injury (serious, often permanent condition caused from complete lack of oxygen to the brain, leading to brain cell death), spastic quadriplegia (jerky movements of the muscle with loss of function affecting both arms and legs) and ventilator dependent (a person's body cannot breath enough on its own to stay alive, so they must rely on a machine (a ventilator) to do the work of breathing for them). During a concurrent interview and record review on April 14, 2026, at 4:28 PM, with the MDS coordinator (MDSC), Resident 19's MDS Annual Assessment (an assessment for a resident that must be completed every 366 days following the previous assessment), dated March 20, 2026, was reviewed. The MDS Annual Assessment under Section I titled Active Diagnoses. Genitourinary (the body's reproductive and urinary organs) . 1550. Neurogenic bladder (loss of bladder function caused by nerve damage from the brain) was left blank which indicated that Resident 19 not having an issue with neurogenic bladder. The MDSC verified and stated the MDS was coded incorrectly and Resident 19 had problem with her bladder. 3. During a review of Resident 20's admission Record and H&P, the admission Record and H&P indicated, Resident 20 was admitted to the facility on [DATE], with diagnoses which included premature infant (born before 37 completed weeks of pregnancy), chronic lung disease (long term lung conditions that obstruct airways, destroy lung tissue, or impair breathing) and seizure. During a concurrent interview and record review on April 16, 2026, at 11:34 AM, with the Director Case Management (CM2), Resident 20's MDS Annual Assessment, dated February 14, 2026, was reviewed. The MDS Annual Assessment under Section I titled Active Diagnoses. Neurological. 15400. Seizure Disorder or Epilepsy was left blank which indicated that Resident 20 did not have a seizure disorder. CM2 verified and stated the seizure was not documented correctly since Resident 20 had seizures. 4. During a review of Resident 23's History and Physical, dated December 12, 2025, the History and Physical indicated Resident 23 was admitted to the facility on [DATE], with diagnoses which included arthrogryposis (characterized by multiple joint stiffness present at birth), chronic lung disease (long-term lung damage that makes breathing on a person's own difficult or impossible, requiring a long-term breathing tube) with tracheostomy (a breathing tube placed directly into a person's windpipe to receive oxygen by a machine), and focal seizures. During a concurrent interview and record review on April 16, 2026, at 12:00 PM, with the CM2, Resident 23's MDS Quarterly Assessment under Section I titled, Active diagnoses (Section I5400 Seizure Disorder or Epilepsy), dated January 21, 2026, was reviewed. The MDS Quarterly Assessment under Section I titled, Active Diagnoses (Section I5400 Seizure Disorder or Epilepsy), was left blank. The CM2 stated the MDS coordinator did not accurately complete Resident 23's MDS Quarterly Assessment-Section I since Active Diagnoses should not be blank. During a concurrent interview and record review on April 16, 2026, at 4:25 PM, with the Chief Nursing Officer (CNO), the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS) Assessments, dated February 6, 2024, was reviewed. The P&P indicated, .Within 14 days after the resident's assessment has been completed, the MDS coordinator or designee must electronically transmit encoded, accurate, and complete MDS data to the QIES ASAP system ([Quality Improvement and Evaluation System - Assessment Submission and Processing] is a secure, web-based system used by healthcare providers to send required patient data to the Centers for Medicare & Medicaid Services). Each individual who completes a portion of assessment must sign and certify the accuracy of that portion of the assessment. The CNO stated the policy was not followed and further stated the quarterly MDS was incorrectly coded.

Based on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) assessment was completed and submitted to CMS in accordance with the required federal submission timeframe for one of two sampled residents (Resident 23).This failure resulted in inadequate monitoring of progress or decline for Resident 23 and the lack of resident specific information to CMS for payment and quality measure monitoring.Findings:During a review of Resident 23's History and Physical (H&P -contains resident's medical history, physical examination and reason for admission to the facility), dated April 14, 2024, the H&P indicated, Resident 23 was admitted to the facility on [DATE], with diagnoses which included arthrogryposis (a rare condition present at birth characterized by multiple stiff joints and limited movements), and multiple congenital anomalies (structural or functional abnormalities that occur during intrauterine life are present at birth).During an interview on April 15, 2026, at 3:45 PM, with the MDS Coordinator Nurse (MDSC), the MDSC stated it is her duty to complete the residents' MDS assessment. The MDSC further stated that the expectation for comprehensive assessment is that it must be completed within 14 calendar days from residents' admission date.During a concurrent interview and record review on April 15, 2026, at 3:55 PM, with the MDSC, Resident 23's Comprehensive MDS assessment data, dated May 2025, was reviewed. The MDSC stated the comprehensive/admission assessment was due on April 28, 2025, and was not done until May 19, 2025 (21 days late).During an interview on April 15, 2026, at 4:50 PM, with the Chief Nursing Officer (CNO), the CNO stated the expectation for the comprehensive/annual assessment is that it must be completed within 14 calendar days from residents' admission date. During a concurrent interview and record review on April 15, 2026, at 5:00 PM, with the CNO, Resident 23's comprehensive MDS assessment data, dated May 2025, was reviewed. The CNO stated that the comprehensive/admission assessment was due on April 28, 2025, and was not done until May 19, 2025. (21 days late).During a concurrent interview and record review on April 15, 2026, at 5:05 PM, with the CNO, the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS) Assessments, dated March 2024, was reviewed. The P&P indicated, Comprehensive assessments must be completed within 14 calendar days after patients' admission, on significant change in status and annually. The CNO stated that policy was not followed and should have been because it provides accurate reimbursement for the facility and care planning for the residents.

Based on interview and record review, the facility failed to ensure the quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS] every 3 months or quarterly) was completed in accordance with federal submission timeframes, for one of two residents (Residents 23) when Resident 23's quarterly RAI/MDS assessment was not completed within 92 days following the previous assessment. This failure had the potential to result in a delay in determining the resources necessary to competently care for the residents during day-to-day operations and emergencies for Resident 23. Findings: During a review of Resident 23's History and Physical (H&P -contains resident's medical history, physical examination and reason for admission to the facility), dated April 14, 2024, the H&P indicated, Resident 23 was admitted to the facility on June April 14, 2024, with diagnoses which included arthrogryposis (a rare condition present at birth characterized by multiple stiff joints and limited movements), and multiple congenital anomalies (structural or functional abnormalities that occur during intrauterine life are present at birth). During an interview on April 15, 2026, at 3:40 PM, with the MDS Coordinator Nurse (MDSC), the MDSC stated it is her duty to complete the resident's RAI/MDS. The MDSC further stated that the expectation for the quarterly assessment is that it must be completed within 92 days from the prior quarterly assessment. During a concurrent interview and record review on April 15, 2026, at 3:45 PM, with the MDSC, Resident 23's quarterly MDS assessment data (RAI/MDS), dated [DATE], was reviewed. There was no documented evidence that RAI/MDS was completed in April 2026. The MDSC stated the last quarterly assessment was completed on January 5, 2026 (100 days from previous). The MDSC further stated she has not completed the quarterly assessment that was due on April 7, 2026 (8 days late). During an interview on April 15, 2026, at 4:40 PM, with the Chief Nursing Officer (CNO), the CNO stated the expectation for the quarterly assessment is that it must be completed within 92 days from the prior quarterly assessment. During a concurrent interview and record review on April 15, 2026, at 4:45 PM with the CNO, Resident 23's quarterly MDS assessment data, dated April 2026, was reviewed. There was no documented evidence that RAI/MDS was completed in April 2026. The CNO stated the last quarterly assessment was completed on January 5, 2026 (100 days from previous). The CNO further stated MDS quarterly assessment was not completed that was due on April 7, 2026 (8 days late). During a concurrent interview and record review on April 15, 2026, at 4:55 PM, with the CNO, the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS) Assessments, dated March 2024, was reviewed. The P&P indicated, Quarterly review assessments (non-comprehensive) must be completed at least 92 days following the previous assessment of any type. The CNO stated that policy was not followed and should have been because it provides accurate reimbursement for the facility and care planning for the residents.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (an individualized plan that includes residents' health problems, preferences and goals) to meet the needs for one of three sampled residents (Resident 46) when Resident 46 was diagnosed and prescribed medication for new on-set seizures (uncontrolled changes in behaviors and movement) and Resident 46's care plan did not reflect this diagnosis. This failure had the potential for safety measures not to be in place, inadequate monitoring, and poor coordination of care which could lead to physical injury and rehospitalization.Findings: During a review of Resident 46's History and Physical (H&P-medical document that provide brief physical exam), dated August 26, 2024, the H&P indicated, Resident 46 was admitted to the facility December 7, 2022, with diagnoses including cerebral palsy (a disorder caused by abnormal brain development or damage to the brain before, during, or shortly after birth that affects muscle control, balance, and posture) and chronic respiratory failure (a condition that lung cannot provide enough oxygen to body). During a review of Resident 46's Discharge Summary, dated January 15, 2026, the Discharge Summary indicated Resident 46 was hospitalized [DATE], through January 15, 2026, with an admitting diagnosis of new on-set seizure. During a review of Resident 46's Neurology [special medical dealing with brain and nervous system] Consult, dated January 22, 2026, indicated, .Recurrent tonic seizures [one type of seizure] . During a review of Resident 46's LTC [Long Term Care] Physician Order Review/Renewal, dated April 15, 2026, the LTC Physician Order Review/Renewal indicated, Resident 46 was prescribed Keppra (medication used to treat patient with seizures) 750 milligrams (mg- unit of measure) twice daily for seizure management and clonazepam (medication used to treat seizures) 0.25 mg once daily for seizures. During a concurrent interview and record review on April 16, 2026, at 3:00 PM, with Case Manager 1 (CM 1), Resident 46's Long Term Care Plan (LTCP), dated April 16, 2026, was reviewed. The LTCP indicated Resident 46's care plan for seizures was initiated today April 16, 2026. CM 1 stated, Resident 46's LTCP for seizure was started today. CM 1 stated that an LTCP should have been put into place upon her return from the hospital on January 15, 2026, but there was no documented evidence of a seizure care plan in Resident 46's electronic chart. CM 1 stated, a LTCP needs to be individualized to each resident and communicate specific resident needs to ensure consistent resident observation and resident care between staff. CM 1 further stated, there should have been an LTCP for Resident 46's new seizure diagnosis. During a concurrent interview and record review on April 16, 2026, at 4:50 PM, with the Chief Nursing Officer (CNO) the facility's policy and procedure (P&P) titled, Interdisciplinary Team Care Assessments, dated December 16, 2024, was reviewed. The P&P indicated, .IDT assessment: Development and implementation of the plan of care begins on completion of assessments. The assessment should include consideration of current medication, psychosocial, environmental, self-care, educational, and discharge planning factors.IDT care plans. Interdisciplinary team conference will be held for each patient on a quarterly basis and more often if needed. Care plans will also be reviewed when indicated by changes in the patient's condition. The CNO stated, when a patient has a new diagnosis, like new on-set seizures, it is expected that staff initiate a care plan related to the diagnosis and new medication immediately.

Based on observation, interview, and record review, the facility failed to provide respiratory and tracheostomy (a surgically created hole in the front of the neck leading directly into the windpipe to help a patient breathe) care consistent with the facilities policy and procedure (P&P) for two of three sampled patients (Patients 14 and 46) when suction canisters (a disposable container that attaches to a suction machine to safely collect bodily fluids) and suction tubing (a hollow plastic tube connected to suction used to remove fluids, mucus, or blood from a patient's body) were not changed weekly and were available for continued patient use. These failures resulted in contaminated and expired supplies being used to suction the airway on immune-compromised (weakened ability to fight infection and disease) patients and had the potential to cause life threatening infection and poor suction potentially causing the obstruction (clogging) of patient airway.Findings: 1. During a review of Patient 14's History & Physical ( H&P - document containing a patient's medical history, physical exam and treatment plan), dated [DATE], the H&P indicated Patient 14 was admitted to the facility on [DATE], with diagnoses including acardi syndrome (a rare genetic disorder that affects the brain and causes severe spasms, distinct eye abnormalities, and moderate-to-severe developmental delays), and respiratory failure (a condition where patient is unable to breath on their own) with tracheostomy and ventilator dependence (a patient relies on a machine to move air in and out of their lungs). During a concurrent observation and interview on [DATE], at 2:55 PM, at Patient 14's bedside, with Respiratory Therapist 1 (RT 1), Patient 14's suction canister and suction tubing were dated [DATE], and contained 500 milliliters (ml - unit of measure) of light greenish liquid. RT 1 confirmed and verified the suction canister and suction tubing were dated [DATE] (13 days from last change). RT 1 stated that the suction canister should be changed at least every seven days. RT 1 stated, the suction canister and suction can be changed more frequently if the items become gunky or dirty to ensure the suction devices are working appropriately and to prevent infection. RT 1 stated that Certified Nurse Assistant (CNA) was responsible for changing the suction canisters and tubing every Sunday or Monday NOC shift (6:00 PM to 6:00 AM), but RT and Registered Nurse (RN) can also change the equipment any time as needed. 2. During a review of Patient 46's H&P, dated [DATE], the H&P indicated, Patient 46 was admitted to the facility on [DATE], with diagnoses including cerebral palsy (a disorder caused by abnormal brain development or damage to the brain before, during, or shortly after birth that affects muscle control, balance, and posture) and chronic respiratory failure with tracheostomy and ventilator dependence. During a concurrent observation and interview on [DATE], at 2:58 PM, at Patient 46's bedside, with RT 1, Patient 46's suction canister and suction tubing were dated [DATE], and contained 750 ml of cloudy green liquid with brownish foam to top and sediment (thick, solid material) on the bottom in the suction canister. RT 1 confirmed and verified the suction canister and suction tubing were dated [DATE] (9 days from last change). RT 1 stated that the suction canister and tubing should be changed at least every 7 days. RT 1 stated, the suction canister and suction can be changed more frequently if the items become gunky or dirty to ensure the suction devices are working appropriately and to prevent infection. RT 1 stated that CNA was responsible for changing the suction canisters and tubing every Sunday or Monday NOC shift, but RT and RN can also change the equipment any time needed. During a concurrent interview and record review on [DATE], at 2:20 PM, with the Chief Nursing Officer (CNO), the facility's P&P tiled, Disposable Equipment, dated [DATE], was reviewed. The P&P indicated, .Disposable equipment will be replaced according to established facility guidelines.The following equipment will be maintained as outlined in the table below and PRN (as needed). Equipment will be labeled with date put in service .Equipment: Suction Tubing, Frequency: weekly, Designated Staff: Nursing/Respiratory. Equipment: Suction Canisters, Frequency: weekly, Designated Staff: Nursing/Respiratory. The CNO stated, it is expected that staff follow the facility's P&P and change the suction canister and suction tubing weekly and more often if the devices become soiled or when the canister is full. During a review of the facility's document title, Job Description: Registered Nurse (JD), dated [DATE], the JD indicated, .C. Medical Equipment and Point of Care Testing: Manages, operates, inspects and tests nursing equipment to ensure that it is functioning safely and efficiently prior to use and removes nonfunctioning equipment from use according to hospital policy. During a review of the facility's document titled, Job Description: Respiratory Therapist (JD), dated [DATE], the JD indicated .B. Medication and Treatment Safety.Performs routine respiratory care procedures as appropriate for clinical patient care areas according to hospital policy and protocols.C. Medical Equipment and Point of Care Testing: Sets-up and monitors mechanical ventilators and the associated critical care duties required for such treatment, such as airway management and tracheal suctioning.Manages, operates, inspects and tests respiratory therapy equipment to ensure that it is functioning safely and efficiently.

Based on observation, interview, and record review, the facility failed to ensure staff followed safe infection control practices when one Licensed Vocational Nurse (LVN 3) did not perform appropriate hand hygiene (cleaning hands with soap and water or sanitizer to remove germs and prevent sickness) practices during wound care for one of one sampled resident (Resident 6). This failure had the potential to result in cross contamination (the transfer of harmful bacteria) and cause a preventable infection for (Resident 6). Findings: During a review of Resident 6's History and Physical (a foundational medical document created by a clinician to understand a patient's health, diagnose issues, and create a care plan), dated June 5, 2024, the History and Physical indicated Resident 6 was admitted to the facility on [DATE], with diagnoses that included quadriplegic (not being able to move both arms and legs), cerebral palsy (a group of permanent movement disorders that appear in early childhood, caused by abnormal brain development or damage to the developing brain. It can affect muscle tone, posture, and motor skills), and erosive right neck wound (a break in the skin or damage to body tissue from long-term pressure). During a review of Resident 6's Medical Doctor (MD) orders, dated March 2, 2026, the MD orders indicated non-pressure ulcer (damage to the skin and tissue caused by constant pressure, friction, or shearing that cuts off blood flow), right neck wound, neck, right, daily, follow instructions-cleanse wound with Normal saline [sterile water and sodium chloride used for cleansing wounds]. Pat dry. Apply skin prep [cleaning and protecting the healthy skin around a wound]. Collagen sheet and Calcium alginate to wound bed (high-tech dressing method designed to speed healing over wound). Cover with Mepilex dressing [a soft, cushioned foam dressing used to treat draining wounds by absorbing fluid while keeping the wound moist for faster healing]. During an observation April 16, 2026, at 8:35 AM, in Resident 6's room, Resident 6 was slightly upright, and head was turned to the left. LVN 3 performed hand hygiene, placed sterile gloves on, and removed Resident 6's old dressing on his right neck area. LVN 3 cleaned the right neck area with sterile (free from living germs, bacteria, or microorganisms) normal saline and gauze (thin, loosely woven, breathable cotton cloth used primarily in medicine to cover wounds, absorb fluids, and secure dressings). Patted wound dry with sterile gauze. LVN 3 then proceeded to apply skin prep to wound. LVN 3 placed collagen and calcium alginate sheet and the new dry dressing without performing hand hygiene and changing her gloves. During an interview on April 16, 2026, at 8:50 AM, with LVN 3, LVN3 acknowledged she did not change her gloves after she removed the old dressing and before she cleansed the wound and applied the new dressing. During a concurrent interview and record review on April 16, 2026, at 2:57 PM, with the Director of Staff Education (DSE), the In-Service training titled, Dressing changes, undated, was reviewed. The Dressing changes indicated, .Use clean gloves, remove soiled dressing first. Discard the old dressing in proper receptacle. Perform hand hygiene again (gel [used to kill viruses, bacteria, and other microorganisms on the hands] is ok), don (put on) sterile gloves. Clean wound as ordered. Apply dressing as ordered. Perform hand hygiene . The DSE stated, The expectation is to wash hands if visibly soiled or perform hand hygiene with sanitizer after old dressing is removed and before cleansing the wound and applying the new dressing. During a concurrent interview and record review on April 16, 2026, at 3:32 PM, with the Chief Nursing Officer (CNO), the facility's policy and procedure (P&P) titled, Hand hygiene: Infection Control, dated October 16, 2025, was reviewed. The P&P indicated, .Decontaminate [clean] hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. The CNO stated the policy was not followed.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from abuse as stated in the facility's policy and procedure (P&P) when a nursing student witnessed Certified Nurse Assistant (CNA 1) used verbally abusive words to Resident 1. This failure had the potential to result in Resident 1 having emotional harm such as feeling unsafe, loss of trust, and can lead to behavioral issues.Findings: An unannounced visit was conducted to the facility on July 18, 2025, for investigation of a facility reported incident of abuse. During a review of Resident 1's Face Sheet (FS- a document containing patient demographics) the FS indicated, Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's Progress Note - Physician (PN- A document containing the progression of the residents and past medical history), dated July 16, 2025, indicated Resident 1 has a history of extreme prematurity (baby born before 28 weeks), short gut (a condition that occurs when the small intestine is damaged or shortened) and is gastrostomy tube (G tube-a tube inserted through stomach to provide nutrition, food, and medication) dependent (someone who relies on G tube). During an interview on July 18, 2025, at 12:25 PM, with Resident 2's mother, Resident 2's mother stated that she has seen CNA 1 be very rough when turning Resident 2. Resident 2's mother further stated that she has brought it up to management before and management stated they would talk to CNA 1. During an interview on July 18, 2025, at 12:45 PM, with CNA 2, CNA 2 stated that she has seen CNA 1 give an attitude to other staff members. During an interview on July 18, 2025, at 1:40 PM, with Resident 1's father, Resident 1's father stated, that the facility called him to let him know that one of the staff members was telling his son Bad things and that they sent that staff member home. Resident 1's father further stated, he is concerned for his son's safety. A review of nursing student's statement Notes, dated July 8, 2025, indicated on July 8, 2025, I went into Resident 1's room with my assigned nurse and witnessed Resident 1 run away from the CNA 1 and grab my nurse's leg. CNA 1 said you better get back in that damn bed and when the CNA 1 checked on another patient, the CNA 1 again said get back in the f****ng bed.During a concurrent interview and record review, on July 18, 2025, at 2:44 PM, with the HR Director (HRD), the employee separation report (document used for termination of an employee), dated July 16, 2025, was reviewed. The employee separation report indicated, [CNA 1] was witnessed verbally abusing a patient in the subacute department [provides level of care between hospital care and skilled nursing care] which is called for immediate termination. The HRD stated that CNA 1 did not sign the document. A review of notice of disciplinary action (document that contains unsatisfactory performance given to staff for them to sign), dated May 27, 2025, in CNA 1's file, indicated there must be immediate improvement in: polite and professional interactions with other at all times. Your negative interactions can cause disruption and jeopardize safe care for our children. During an interview on July 18, 2025, at 3:46 PM, with the Chief Nursing Officer (CNO), the CNO stated verbal abuse is anything that can be intimidating to residents, using foul language especially at a child. During a concurrent interview and record review on July 18, 2025, at 3:48 PM, with the CNO, the child abuse reporting requirement for CNA 1, dated May 3, 2024, was review. The child abuse reporting requirement indicated, resident abuse can take many forms including, but not limited to, tone of voice, name calling, swearing, threats, theft of possession.I am aware of the requirements stated above and will comply with these requirements. I understand that this signed statement will be maintained in my personal file.signed by CNA 1 on May 3, 2024. The CNO verified and stated, this was not followed and should have been. During a concurrent interview and record review on July 18, 2025, at 3:50 PM, with the CNO, the P&P titled, abuse: screening, training, prevention, identification, investigation, protection, and reporting/response, dated July 18, 2024, was reviewed. The P&P indicated .patients have the right to be free from mental, physical, sexual and verbal abuse.verbal abuse any use of oral, written, gestured language that includes disparaging [something that is little worth] and derogatory [disrespectful attitude] terms to patients. The CNO stated that the policy was not followed and should have been. The CNO further stated, everyone has the right to be free from abuse and this situation is never acceptable.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS- a facility assessment tool that consists of the resident assessment instrument (RAI) and the care area assessment (CAA) was conducted and submitted to the Centers of Medicare and Medicaid Services (CMS) in accordance with federal submission timeframes, for nine of nine residents (Residents 1, 2, 6, 21, 23, 24, 31, 38, and 42) reviewed for resident assessment. These failures resulted in inadequate monitoring of progress or decline for Residents 1, 2, 6, 21, 23, 24, 31, 38, and 42), and a lack of resident specific information to be sent to CMS for payment and quality measure monitoring. Findings: During a concurrent interview and record review on January 9, 2025, at 9:13 AM, with the Director of Case Management (DCM), Resident 1, 2, 6, 21, 23, 24, 31, 38, and 42's Electronic Health Records (EHR), and CMS Submission Reports (a report with details of when MDS assessments were completed and submitted to CMS) were reviewed. The DCM stated resident MDS assessments were supposed to be done quarterly or approximately every 90 days. The DCM further stated multiple residents had their MDS assessments completed late in November 2024 because she (the DCM) was the only individual that was able to enter the assessments when usually there were more people to help with the task. Resident 1, 2, 6, 21, 23, 24, 31, 38, and 42's EHR, and CMS Submission Reports were reviewed and the following was identified: -For Resident 1, the CMS Submission Report, (undated), indicated the MDS assessment dated [DATE], was not completed until December 23, 2024 (70 days after the due date). The DCM stated Resident 1's MDS assessment was completed late. -For Resident 2, the CMS Submission Report, (undated) and the residents EHR, indicated the residents most recent MDS assessment was dated August 27, 2024, and there was no MDS assessment completed after this date (135 days since the most recent MDS assessment). The DCM stated Resident 2's MDS assessment should have been done sometime in November 2024, but it was never completed and must have been missed. -For Resident 6, the CMS Submission Report, (undated) indicated the MDS assessment dated [DATE], was not completed until January 8, 2025 (43 days after the due date). The DCM stated Resident 6's MDS assessment was completed late. -For Resident 21, the CMS Submission Report, (undated) and the residents EHR indicated the residents most recent MDS assessment was dated August 4, 2024, and there was no MDS assessment completed after this date (157 days since the most recent MDS assessment). The DCM stated Resident 21 was supposed to have an MDS assessment done in November 2024, but it was never completed and must have been missed. -For Resident 23, the CMS Submission Report, (undated), indicated the MDS assessment dated [DATE], was not completed until January 8, 2025 (56 days after the due date). The DCM stated Resident 23's MDS assessment was completed late. -For Resident 24, the CMS Submission Report, (undated), indicated the MDS assessment dated [DATE], was not completed until January 7, 2025 (69 days after the due date). The DCM stated Resident 24's MDS assessment was completed late. -For Resident 31, the CMS Submission Report, (undated), indicated the MDS assessment dated [DATE], was not completed until January 8, 2025 (51 days after the due date). The DCM stated Resident 31's MDS assessment was completed late. -For Resident 38, the CMS Submission Report, (undated), indicated the MDS assessment dated [DATE], was not completed until January 6, 2025 (56 days after the due date). The DCM stated Resident 38's MDS assessment was completed late. -For Resident 42, the CMS Submission Report, (undated), indicated the MDS assessment dated [DATE], was not completed until January 8, 2025 (47 days after the due date). The DCM stated Resident 42's MDS assessment was completed late. During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS) Assessments, revised March 7, 2024, the P&P indicated, A comprehensive assessment of a patient's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS must be completed for all patients in [name of facility] .Assessments are completed within specific guidelines and timeframes. MDS assessments are transmitted electronically to the national MDS database at CMS. - Comprehensive assessments must be completed within 14 calendar days after patient admission, on significant change in status and annually. - Quarterly review assessment (non-comprehensive) must be completed at least every 92 days following the previous assessment of any type .

Based on interview and record review, the facility failed to ensure the pharmacists Monthly Medication Review (MRR- a review of patient medications by a pharmacist aimed at optimizing the health outcomes of residents) was reviewed in a timely manner for two of 50 residents dated October 1, 2024, through October 31, 2024, when the facility failed to implement a policy and procedure (P&P) that included timelines and steps to be followed once the MRR was received. This failure resulted in a delay of two months in physician review of the MRR recommendations provided by the pharmacist and had the potential for an urgent recommendation to go unnoticed, that could have resulted in residents' harm. Findings: During an interview on January 9, 2025, at 2:49 PM, with the Pharmacist (PharmD), the PharmD stated he performs a monthly MRR and at the beginning of each month, for the previous month, then sends a copy to the Chief Nursing Officer (CNO) of the facility. The PharmD stated, it is the facilities responsibility to review his recommendations at the beginning of each month with the resident's physician. The PharmD further stated, the facility should have their own policies to ensure the MRR recommendation are reviewed and acknowledged. During a concurrent interview and record review on January 9, 2025, at 3:43 PM, with the CNO 1, the Consultant Pharmacists Recommendations, dated October 1, 2024, through October 31, 2024, was reviewed. The Consultant Pharmacists Recommendations indicated, the recommendations for antipsychotics (medication to treat hallucination) and hynoptics (medication to help sleeping) medication were received on November 6, 2024, reviewed, and responded by the attending physicians on January 9, 2025, two months after being received. The CNO 1 stated, there was a two- month delay in physicians response to the recommendations by the PharmD and the goal for review is one week. During a concurrent interview and record review on January 9, 2025, at 3:45 PM, with the CNO 1, the Consultant Pharmacists Recommendations, dated April 1, 2024, through April 30, 2024, was reviewed. The Consultant Pharmacists Recommendations were not dated with a received date and were reviewed and responded by the physician on July 15, 2024. The CNO 1 stated, there was over a two-month delay in physician response to the recommendations made by the PharmD and the goal for response is one week. The CNO 1 stated, she had delegated one of the nurses to review the MRR with the physicians, and two months for a physician to review and response to the PharmD recommendations is not acceptable. During a concurrent interview and record review on January 9, 2025, at 3:50 PM with the CNO 1, the facility's policy and procedure P&P titled, Medication Regimen Chart Review, dated July 01, 2020, was reviewed. The P&P indicated, .The designated pharmacist will monitor medication therapy. Completion of each regimen review will be dated and documented. Potential or actual medication therapy issues are communicated to the physician. For those requiring the immediate attention of a physician; the responsible physician, or his/her designee is contacted by the pharmacist or nurse caring for the patient . The CNO 1 stated, the policy does not outline the facilities expectation related to the MRR and physician review or outline time frames for the process. The CNO 1 stated, it is the expectation to have the physician review and have all recommendations addressed within a week and returned. The CNO 1 further stated, if there was an urgent concern requiring immediate action to a resident's medications, the recommendation would be brought to her attention immediately by the PharmD or nursing staff so that changes could be made timely.

Based on observation, interview and record review, the facility failed to ensure infection control practices were developed and maintained for two of 20 sampled residents (Residents 7 and 10) when: 1. Enhanced Barrier Precautions (EBP - extra steps taken to prevent the spread of germs to vulnerable residents during close contact care by wearing gowns and gloves) were not implemented when providing wound care for one resident (Resident 10). 2. Sterile technique (the use of practices that restrict microorganisms in the environment and prevent contamination of the field) was not followed during urinary catheterization (procedure where a thin, flexible tube called a catheter is inserted into the urethra to drain urine from the bladder) for one resident (Resident 7). 3. Hand hygiene (hand washing) was not performed after resident care for one resident (Resident 7). These failures had the potential for an increased risk of a health-care associated infection (HAI - an infection that is unintentionally caused when receiving treatment at a medical facility) or exposure to a Multiple Drug Resistant Organism (MDRO - germs that resist treatment with more than one antibiotic) which can result in a preventable infection and worsening of medical condition. Findings: 1. During a review of Resident 10's History and Physical (H&P - a formal assessment document by the residents physician), dated June 10, 2024, the H&P indicated, Resident 10 was admitted to the facility on [DATE], with diagnoses including [NAME] syndrome (a genetic disorder that causes physical abnormalities in the face, arms, hands, and feet) and currently hospitalized for wounds secondary to tracheostomy (trach - a hole made during a surgical procedure to help air and oxygen reach the lungs) ties (used to secure the tracheostomy in place). During an observation on January 8, 2025, at 9:33 AM, at Resident 10's bedside, Registered Nurse 1 (RN 1) and Respiratory Therapist 1 (RT 1) provided wound care to erosive wounds (wounds caused to the resident's neck from tracheostomy dressing change) for Resident 10. RN 1 and RT 1 did not wear gowns during these high contact care activities. During a concurrent interview and record review, on January 8, 2025, at 3:00 PM, with the Infection Preventionist (IP 1), the facility's policy and procedure (P&P) titled, Isolation Precautions, dated February 24, 2023, was reviewed. The P&P did not include EBP procedure. The IP 1 stated, this is the only policy regarding any isolation precautions or use of personal protective equipment (PPE - equipment like gloves, gowns, masks and face shields that can minimize exposure and transmission of infection) and the P&P did not address EBP regulatory standards and did not specify when gowns need to be worn to protect residents at high risk of infection from MDRO during high-risk care. The IP 1 further stated, she was aware of the EBP regulation requirements, but the P&P had not been updated and EBP had not been implemented within the facility. The IP 1 further stated, not wearing a gown during high-contact care, such as wound care, could spread MDRO. During a concurrent interview and record review, on January 9, 2025, at 2:00 PM, with the [NAME] President of Regulatory Compliance (VPR), the Centers for Medicare & Medicaid Services (CMS) Memorandum titled, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-24-08-NH (QSO-24-08-NH), dated March 20, 2024, was reviewed. The QSO-24-08-NH memorandum indicated, .CMS is issuing new guidance for State Survey Agencies and long-term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status . The VPR stated, the facility has not yet adopted the EBP procedure and does not have a policy specific to EBP. 51269 2. During a record review of Resident 7's Admission Record (contains the admitted ) and History and Physical (H&P-contains demographic information), the Admission Record indicated Resident 7 was admitted to the facility on [DATE]. The H&P indicated Resident 7 was admitted with diagnoses of anoxic encephalopathy (a serious condition that occurs when the brain is deprived of oxygen, causing brain cells to die), neurogenic bladder (a condition that occurs when the nerves that control the bladder are damaged, resulting in a loss of bladder control), and spasticity (a serious condition that occurs when the brain is deprived of oxygen, causing brain cells to die). During an observation on January 9, 2025, at 9:22 AM through 9:35 AM, with a Licensed Vocation Nurse (LVN 3), in Resident 7's room, LVN 3 was observed preparing the catheterization kit (a collection of supplies used to insert a catheter into a body cavity) and irrigation (the process of washing out an organ or wound with a continuous flow of water or medication.) supplies needed to straight catheterize (procedure where a thin, flexible tube called a catheter is inserted into the urethra to drain urine from the bladder) Resident 7. LVN 3 then proceeded, with non-sterile gloves, to touch everything inside of the sterile (free from bacteria or other living microorganism; totally clean) kit. LVN 3 placed the drape that goes under Resident 7, pulled out the iodine swabs, opened the swabs and placed them on top of the drape that was under Resident 7. LVN 3 placed the half-opened catheter to the right side of the bed. LVN 3 removed gloves and donned (the processes of putting on personal protective equipment (PPE)) sterile gloves and used the iodine swabs to cleanse the genitals. LVN 3 then proceeded to toss the iodine swabs on the sterile drape and noticed the catheter was still in the package. With the same gloves, LVN 3 opened the package and placed the catheter in the kit to lubricate it. During an interview on January 9, 2025, at 9:55 AM, with LVN 3, LVN 3 stated, the straight catheterization should have been performed with sterile technique. LVN 3 further stated, she should not grab inside the sterile kit with her non-sterile gloves since it increases the risk of spreading infection. During a concurrent interview and record review on January 9, 2025, at 12:25 PM, with the Nurse Manager (NM) and the Chief Nursing Officer (CNO 1), the facility's policy and procedure (P&P) titled, Urinary Catheterization, dated April 21, 2021, was reviewed. The P&P indicated, . use sterile technique to insert the catheter. The NM and the CNO 1 stated the policy was not followed and should have been due to the risk of a resident developing a urinary tract infection if proper sterile technique is not performed. 3. During a record review of Resident 7's Admission Record and H&P, the Admission Record indicated Resident 7 was admitted to the facility on [DATE]. The H&P indicated Resident 7 was admitted with diagnoses of anoxic encephalopathy, neurogenic bladder, and spasticity. During an observation on January 9, 2025, at 9:40 AM through 9:53 AM, with LVN 3 and a Certified Nursing Assistant 3 (CNA 3), in Resident 7's room, LVN 3 was observed to unable to insert a catheter to drain Resident 7 urine during straight catheterization. LVN 3 stated to CNA 3, I am going to leave it in there and get another kit. LVN 3 proceeded to remove her gloves, got the keys out, and went to open medication cart located in the room without performing hand hygiene. LVN 3 stepped out of the room without performing hand hygiene to grab another catheterization kit. During an interview on January 9, 2025, at 9:55 AM, with LVN 3, LVN 3 stated she did not remember if she washed her hands after the second attempt of straight catheterization. LVN 3 further stated she was supposed to wash hands after any contact with residents prevent spreading infections. During a concurrent interview and record review on January 9, 2025, at 12:25 PM, with the NM and the CNO 1, the facility's P&P titled Infection Control-General, dated February 24, 2023, was reviewed. The P&P stated . Standard Precautions [set of infection control practices that are used to prevent the spread of disease in healthcare settings] and appropriate hand hygiene should be used with all patient care activities . The NM and the CNO 1 stated the policy were not followed and should have been due to the risk of a resident developing a urinary tract infection if proper hand hygiene is not performed. The CNO 1 further stated, the facility also followed the Centers for Disease Control and Prevention (CDC) guideline that staff are expected to wash their hands before entering and leaving a resident's room.

Based on observation, interview, and record review, the facility failed to ensure a medication was stored in accordance with the facility's policy and procedure (P&P) when one bottle of Humulin R ( a short-acting medication used to lower blood sugar) 100 units per milliliter (ml-units of measurement) medication was found with an expiration date of [DATE] (33 days expired) in one of four medication emergency kits (E-Kit- a collection of medications and supplies that can be used to treat medical emergencies when pharmacy services are unavailable). This failure had the potential to cause unsafe medication administration and care during an emergency situation to residents from beyond the use date (expired) medication. Findings: During a concurrent observation and interview on [DATE], from 3:55 PM through 4:20 PM, with the Charge Nurse (CN 1) in a medication storage room where refrigerated medications were kept, one refrigerated medication E-Kit was found with an expiration date of [DATE]. The CN1 confirmed the E-Kit was expired and further stated this failure had the potential for expired medication to be administered or not be readily available during an emergency which could be detrimental to a resident's health and safety. During a follow-up concurrent observation and interview on [DATE], at 4:21 PM, with the CN1 and Nurse Manager (NM), the E-Kit with an expiration date of [DATE] was opened. One medication, Humulin 100 units per ml, was found with an expiration date of [DATE]. The NM confirmed and stated the medication was expired 33 days and further stated the E-Kit should not be stored in the medication fridgerator if it is expired. During concurrent interview and record review on [DATE], at 9:20 AM, with the Chief Nursing Officer (CNO 1), the facility's P&P titled, Medication Management, dated [DATE], was reviewed. The P&P indicated, .Any expired, damaged and/or contaminated medications shall be removed from drug storage areas as soon as possible and disposed appropriately . The CNO 1 stated the policy was not followed and should have been. During a phone interview on [DATE], at 3:35 PM, with the in-house Director of Pharmacy (DP), the in-house DP stated the nurses are involved in the process to make sure medications are not expired and if an expired medication is found, they are to remove the medication from stock and notify the pharmacy for replacement. The in-house DP further stated, the E-Kit should have been readily available without any expired medication due to the risk of potential harm to the residents in an emergency. During a concurrent interview and record review on [DATE], at 4:30 PM, with the CN 2, a document titled, Subacute Charge Nurse Report, dated [DATE], and [DATE], was reviewed. The Subacute Charge Nurse Report indicated the E-Kit was checked by the nurse on both dates. The CN2 stated the E-kits should not have been expired and further stated the nurse checking should have found the expired dates and called the pharmacy for replacement to prevent potential harm to the residents needing to receive the emergency medication.

Based on observation, interview, and record review, the facility failed to follow safe and sanitary food storage practices when: - Seven onions located in the facility's dry storage area, were available for use and labeled with an expired use by date. - Ice cream in the facility's walk-in freezer was found unlabeled. These failures had the potential to compromise the integrity of the food and cause foodborne illness to three of fifty vulnerable residents who received food from the kitchen. Findings: During a concurrent observation and interview on [DATE], at 7:44 AM, with [NAME] 1 (CK 1), in the facility's dry storage area of the kitchen, there was a bin located on a shelf which contained seven onions. The onion bin had a label which indicated, Onions whole .prep [DATE] .use through [DATE] (three days expired). CK 1 observed the onions and stated the onions should not be available for use and should have been thrown away. CK 1 then removed the onions from the dry storage area. During a concurrent observation and interview on [DATE], at 8:02 AM, with CK 1, in the facility's walk-in freezer, there was a large 1-gallon bucket of ice cream on a shelf. The gallon bucket of ice cream was not labeled by the facility with the date it was received or with the date it was to be used by. CK 1 observed the unlabeled bucket of ice cream and stated it was supposed to be labeled with a received date and a use by date, but it was not. CK 1 further stated she was unsure of exactly when it was bought or received but stated the ice cream was purchased for an employee Christmas party. The ice cream was not labeled for employee or staff use. During an interview on [DATE], at 3:25 PM, with the Registered Dietician 1 (RD 1), RD 1 stated when food was received by the facility, it was supposed to be labeled to indicate when it was received or prepared and a date when it was supposed to be used by. RD 1 further stated food for employee meetings or staff parties were kept in the same walk-in freezer where resident food was stored. RD 1 stated employee food was supposed to be labeled or identified in some way to indicate it was food for employees and not residents. RD 1 further stated it was not the ideal practice to have unlabeled food in the fridge or freezer. During a follow up interview on [DATE], at 3:35 PM, with RD 1, RD 1 stated onions were ok to be stored for 30 days in the dry storage area. RD 1 further stated onions should be labeled for the date they are received and the date they were to be used by and are only good for 30 days. During a review of the facility provided document (provided by RD 1), which was untitled, and undated, the document indicated, Onions .for freshness and quality, this item should be consumed within: 1 month if in the pantry from the date of purchase . During a review of the facility's policy and procedure P&P titled, Labeling and Dating of Food, revised [DATE], the P&P indicated, A labeling and dating machine will be utilized in the Nutritional Services Department to ensure food items are rotated and used by expiration dates.

Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 42) had a comprehensive care plan (an individualized plan for the medical care of a resident) in place for his tracheostomy (an opening into the trachea [windpipe] from outside the neck to help air and oxygen reach the lungs) and ventilator dependent status (someone who requires a machine [ventilator] to breathe because they are unable to breathe independently.) This failure had the potential for Resident 42 to have unidentified care concerns related to the monitoring and care of his tracheostomy or ventilator dependent status. Findings: During a review of Resident 42's clinical record and the face sheet (contains demographic and medical information), the face sheet indicated Resident 42 was admitted on [DATE], with diagnoses which included dependence on respirator [ventilator] status (a medical condition where a patient is unable to breathe independently and requires continuous support from a mechanical ventilator (respirator) to maintain adequate oxygen levels), tracheostomy status, and bronchopulmonary dysplasia (a chronic lung disease that affects newborns, particularly those who are born prematurely or have low birth weight). During an observation on January 6, 2025, at 10:37 AM, Resident 42 had a tracheostomy and required the use of a ventilator. During a review of Resident 42's Minimum Data Set assessment (MDS assessment - an electronic assessment tool), dated August 22, 2024, the MDS assessment indicated Resident 42 received oxygen therapy, suctioning, tracheostomy care, and mechanical ventilation. During a review of Resident 42's clinical record, there was no active care plan for Resident 42's respiratory status. During a review of Resident 42's physician's orders, dated August 11, 2024, indicated, tracheostomy care, q 24 [every 24hr], change trach ties [a band that secures a tracheostomy tube around the neck] cleanse trach site every AM with sterile water and prn [as needed] re: [regarding] soiling. During a concurrent interview and record review on January 8, 2025, at 3:11 PM, with the Director of Respiratory Therapy (DRT), Resident 42's clinical record was reviewed and there was no evidence of an active respiratory care plan. The DRT stated Resident 42 was supposed to have a respiratory care plan but does not. The DRT further stated the care plan was usually initiated by case management. During a concurrent interview and record review on January 9, 2025, at 9:47 AM, with the Director of Case Management (DCM), the DCM stated the case management department was the department which initiated care plans for the residents. Resident 42's clinical record was reviewed, and the DCM stated she was unable to find an active respiratory care plan. The DCM further stated Resident 42 was supposed to have a respiratory care plan in place but it fell off on November 19, 2024, because someone mistakenly indicated the goal was met and the care plan was closed out and no longer active. During a review of the facility's policy and procedure titled, Plan of Care, dated January 11, 2024, the policy indicated, [name of facility] provide comprehensive medical, therapeutic, and clinical services to patients in a relevant individualized manner. Each patient and his/her parent/guardian participate in the development of their individual plan of care that includes problems identified, measurable goals, and applicable interventions. Care plans are used as a measure of goal progress, discharge planning, and communication among all interdisciplinary team (IDT) members including the patient, family, clinicians, therapists, dieticians, etc .

Based on observation, interview, and record review, the facility failed to ensure controlled medications (medications that are controlled by the government because it may be abused or cause addiction) verification process was not accurately completed for two of seven medication carts (room [ROOM NUMBER] and room [ROOM NUMBER] medication cart) when the medication verification was not completed and signed with two (2) licensed nurses. This failure had the potential to cause the diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 50 patients. Findings: 1. During a concurrent observation and interview on January 7, 2025, at 2:59 PM, with a License Vocational Nurse (LVN 2), room [ROOM NUMBER]'s medication cart, the Controlled Substance Inventory Count (CSIC- a form used by the facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses), for Valtoco (a medication used to treat episodes of uncontrolled bodily movements) 15 milligram (MG-unit of measurement) Nasal Spray, dated December 9, 2024, to December 31, 2024, was reviewed. The CSIC indicated the following: a. On December 20, 2024, missing signature from the night shift (6:00 PM to 6:00 AM), oncoming nurse. b. On December 21, 2024, missing signature from the day shift (6:00 AM to 6:00 PM), oncoming nurse. c. On December 21,2024, missing signature from the day shift, off going nurse. d. On December 31, 2024, missing signature from the day shift, oncoming nurse. LVN 2 confirmed the missing signatures on the CSIC form and stated oncoming and off going nurses must sign the form during every change of shift and indicate if there are any missing discrepancy counts. 2. During a concurrent observation and interview on January 7, 2025, at 3:04 PM, with LVN 2, room [ROOM NUMBER]'s medication cart, the CSIC for Valtoco 5 MG Nasal Spray, dated January 4, 2025, to January 7, 2025, was reviewed. The CSIC indicated, on January 7, 2025, missing signature from the day shift, oncoming nurse. LVN 2 confirmed the missing signature on the CSIC form and stated the missing signature for today at 6:00 AM should have been signed when she counted with the off going nurse in the morning but she had forgotten and left the room. During a concurrent interview and record review on January 8, 2025, at 3:29 PM, with the Chief Nursing Officer/Vice President of Patient Care Services (CNO 1), the facility's policy and procedure (P&P) titled, Controlled Substance Management-Nursing, dated November 12, 2020, was reviewed. The P&P indicated .Accountability: At the change of each shift, both the licensed nurse leaving the shift and the nurse coming on duty must verify the count of controlled substances documented in both controlled Substances Count sheets 3019-2 (SA) and 2019-6 (H). The CNO 1 stated policy was not followed.

Based on interview and record review the facility failed to ensure the PRN (as needed) lorazepam (anti-anxiety drug) medication order did not exceed 14 days time limitation without the prescriber's documented rationale in the resident's medical record for one (Resident 99) of five residents reviewed for medications. This failure had the potential to result in adverse health outcomes, including but not limited to exposure to unnecessary medications, side effects, and/or habit-forming mental or physical dependence. Findings: During a review of Resident 99's clinical record and face sheet (contains medical and demographic information), the face sheet indicated Resident 99 was admitted on [DATE], with diagnoses which included tracheostomy status (an opening into the trachea [windpipe] from outside the neck to help air and oxygen reach the lungs), hypoxic ischemic encephalopathy (a brain injury that occurs when the brain doesn't receive enough oxygen or blood flow), and extreme immaturity of newborn, gestational (period of time between conception and birth) age 23 completed weeks. During a review of Resident 99's Electronic Health Record (EHR) and physician's orders, an order dated December 20, 2024, indicated, Lorazepam 0.8 mg [milligram - unit of measure], gastrostomy [via feeding tube inserted into the stomach], q8hr [every eight hours], PRN [as needed] agitation, first dose: 12/20/24 [December 20, 2024], 4 week(s), refill #0, indication: agitation . Further review indicated the order was discontinued on January 8, 2024 (order was active for 20 days). During a review of Resident 99's Medication Administration Record (MAR - a document used by staff to record the administration of medications to residents), dated December 2024, through January 2024, the MAR indicated the resident received the Lorazepam medication on the following dates and for the following documented reasons: 12/21/24 for Reason for medication .agitation.; 12/25/24 reason for medication .agitation; 12/26/24 for reason for medication .agitation; 12/27/24 reason for medication .agitation; 12/28/24 at 0639 reason for medication .agitation; 12/28/24 at 1554 reason for medication .agitation; 12/31/24 at 0825 reason for medication .agitation; 12/31/24 at 2051 reason for medication .agitation; 1/1/25 at 1708 reason for medication .agitation. During a review of Resident 99's EHR, there was no prescriber documentation regarding rationale of why the PRN psychotropic medication (Lorazepam 0.8 mg, gastrostomy, q8hr, PRN agitation, first dose: 12/20/24, 4 week(s), refill #0, indication: agitation) was written with a duration of longer than 14 days. During an interview on January 9, 2025, at 2:48 PM, with the Pharmacist 1 (Pharm 1), the Pharm 1 stated he was unable to review medical records, at the time of interview, because his current location was experiencing a power outage. Pharm 1 stated he was the individual who performed the facility's monthly medication regimen reviews for the residents. When asked what the expectation was regarding the duration of psychotropic PRN medication orders, Pharm 1 stated per regulation, psychotropic medication orders were supposed to be re-written every 14 days and re-evaluated periodically after that. Pharm 1 was informed of the physician order for Resident 99, dated December 20, 2024, which indicated, Lorazepam 0.8 mg, gastrostomy, q8hr, PRN agitation, first dose: 12/20/24, 4 week(s), refill #0, indication: agitation. Pharm 1 stated he would consider the duration of the PRN medication order to be an irregularity since it was more than 14 days. During a concurrent interview and record review on January 9, 2025, at 3:12 PM, with the Chief Nursing Officer (CNO 1), Resident 99's clinical record and physician's orders were reviewed. The CNO 1 reviewed the physicians order dated December 20, 2024, which indicated Lorazepam 0.8 mg, gastrostomy, q8hr, PRN agitation, first dose: 12/20/24, 4 week(s), refill #0, indication: agitation. The CNO 1 then confirmed the order was active from December 20, 2024, through January 8, 2024 (20 days). Resident 99's clinical record was reviewed, and the DON was unable to find documented rationale from the prescriber indicating the need for the psychotropic medication beyond 14 days. During continued interview on January 9, 2025, at 3:12 PM, with the CNO 1, the CNO 1 Stated the facility did not have a policy and procedure regarding PRN psychotropic medication orders and that the facility relied upon the pharmacist to review the drug regimen review of the residents and ensure the orders were within regulations and met requirements.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS- a facility assessment tool) assessment was submitted and completed to the Centers of Medicare and Medicaid Services (CMS) in accordance with federal submission timeframes, for four of four residents reviewed for resident assessment (Residents 8, 14, 21, and 41). These failures resulted in inadequate monitoring of Residents 8, 14, 21, and 41's progress and decline, and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: 1. During an interview, with the Case Management Nurse (CMN 1), on January 12, 2024, at 8:48 AM, the CMN 1 stated the MDS assessments were to be submitted and completed to CMS within 14 days of the Assessment Reference Date (ARD- time frame in which the assessment was to be completed). During a review of Resident 41's clinical record, the Face Sheet (contains demographic and medical information) and the History and Physical indicated Resident 41 was admitted to the facility on [DATE], with diagnoses which included bronchopulmonary dysplasia (lungs and the airways are damaged, causing tissue destruction in the tiny air sacs of the lung), short gut syndrome ( body cannot absorb enough nutrients from food because part of the small intestine in missing or damaged), and prematurity (babies born alive before 37 weeks of pregnancy are completed) of infant. During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 10:39 AM, the CMN 1 reviewed Resident 41's quarterly and annual assessment and stated Resident 41's MDS quarterly assessment for November 7, 2023, was not submitted and completed within 14 days of the ARD (48 days overdue). The CMN 1 further stated Resident 41's MDS annual assessment for August 7, 2023, was not submitted and completed within 14 days of the ARD (25 days overdue). 2. During a review of Resident 14's clinical record, the Face Sheet and the History and Physical indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included hypoxic ischemic encephalopathy (a type of brain damage caused by a lack of oxygen to the brain before or shortly after birth), dyskinetic cerebral palsy (trouble controlling muscle movements that affect a person ability to move and maintain balance and posture) and respiratory failure with tracheostomy (a hole created in the windpipe [throat] that provides an alternative airway for breathing). During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 10:42 AM, the CMN 1 reviewed Resident 14's quarterly and annual assessment and stated Resident 14's MDS quarterly assessment for October 25, 2023, was not submitted and completed within 14 days of the ARD (61 days overdue). The CMN 1 further stated Resident 14's MDS annual assessment for July 25, 2023, was not submitted and completed within 14 days of the ARD (10 days overdue). 3. During a review of Resident 8's clinical record, the Face Sheet and the History and Physical indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, diabetes insipidus (causes the fluids in the body to become out of balance where you pee a lot and feel thirsty a lot), tracheostomy, and spastic quadriplegia ((affects both arms and legs and often the torso and face) cerebral). During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 10:45 AM, the CMN 1 reviewed Resident 8's quarterly and annual assessment and stated Resident 8's MDS quarterly assessment for November 1, 2023, was not submitted and completed within 14 days of the ARD (58 days overdue). The CMN 1 further stated Resident 8's MDS annual assessment for May 2, 2023, was not submitted and completed within 14 days of the ARD (22 days overdue). 4. During a review of Resident 21's clinical record, the Face Sheet and the History and Physical indicated Resident 21 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, seizures (a sudden, uncontrolled burst of electrical activity in the brain), and spastic quadriplegic palsy. During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 10:48 AM, the CMN 1 reviewed Resident 21's quarterly and annual assessment and stated Resident 21's MDS quarterly assessment for November 5, 2023, was not submitted and completed within 14 days of the ARD (51 days overdue). The CMN 1 further stated Resident 8's MDS annual assessment for May 9, 2023, was not submitted and completed within 14 days of the ARD (27 days overdue). During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 11:04 AM, the CMN 1 stated they do not have a policy for submitting the MDS Assessment but stated the facility follows the guidelines from the Resident Assessment Instrument (RAI- helps gather definitive information on a resident's strengths and needs). The RAI manual titled, 42 CFR 483.20 .Resident Assessment, indicated .(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS system . She acknowledged the RAI manual was not followed and should have been because it helps identify any issues in resident care and adjustments to interventions for the residents and identifying any concerns for MDS. During a review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, page 5-2, it indicated .For all non-Admission OBRA and PPS assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after Assessment Reference Date (ARD) (A2300). Further review on page 5-3, it indicated Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).

Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS- a facility assessment tool that consists of the resident assessment instrument (RAI) and the care area assessment (CAA)) assessment was completed and submitted to the Centers of Medicare and Medicaid Services (CMS) in accordance to federal submission timeframes, for four of four residents (Residents 41, 14, 8, and 21) reviewed for resident assessment. These failures resulted in inadequate monitoring of Residents 41, 14, 8, and 21's progress and decline, and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: 1. During a review of Resident 41's clinical record, the Face Sheet (contains demographic and medical information) and the History and Physical indicated Resident 41 was admitted to the facility on [DATE], with diagnoses which included bronchopulmonary dysplasia (lungs and the airways are damaged, causing tissue destruction in the tiny air sacs of the lung), short gut syndrome ( body cannot absorb enough nutrients from food because part of the small intestine in missing or damaged), and prematurity (babies born alive before 37 weeks of pregnancy are completed) of infant. During an interview with the Case Management Nurse (CMN 1), on January 12, 2024, at 8:48 AM, the CMN 1 stated one of her duties was MDS. She stated the MDS quarterly assessment must be completed within 90 days, and it must be submitted to CMS within two weeks after the ARD (Assessment Reference Date- specific end point of look-back periods in the MDS assessment process). During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 9:00 AM, the CMN 1 reviewed Resident 41's MDS quarterly assessment record and stated the ARD date was November 7, 2023, but it was completed on December 16, 2023, which was 39 days past the ARD. The CMN 1 further stated It was late. 2. During a review of Resident 14's clinical record, the Face Sheet and the History and Physical indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included hypoxic ischemic encephalopathy (a non-specific term for brain dysfunction caused by a lack of blood flow and oxygen to the brain), dyskinetic cerebral palsy (a brain injury that occurs during late pregnancy or the early birth period), and respiratory failure (a condition that makes it difficult to breath on your own). During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 9:10 AM, the CMN 1 reviewed Resident 14's MDS quarterly assessment record and stated the ARD date was October 25, 2023, but it was completed on December 16, 2023, which was 52 days past the ARD. 3. During a review of Resident 8's clinical record, the Face Sheet and the History and Physical indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included of alobar holoprosencephaly (birth defect that cause the brain not properly separate into right and left halves), congenital hydrocephalus (congenital anomalies of the central nervous system), and panhypopituitarism (the production and secretion of all hormones by the pituitary gland is reduced). During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 9:20 AM, the CMN 1 reviewed Resident 8's MDS quarterly assessment record and stated the ARD date was November 1, 2023, but it was completed on January 11, 2024, which was 71 days past the ARD. 4. During a review of Resident 21's clinical record, the Face Sheet and the History and Physical indicated Resident 21 was admitted to the facility on [DATE], with diagnoses which included prematurity, genetic gap abnormality (disorder caused by gene mutation), severe intellectual disability (Major delays in development), and seizure disorder (happen as a result of abnormal electrical brain activity). During a concurrent interview and record review with the CMN 1, on January 12, 2024, at 9:30 AM, the CMN 1 reviewed Resident 21's MDS quarterly assessment record and stated the ARD was November 5, 2023, but it was completed on December 26, 2023, which was 51 days past the ARD. A review of the facility policy and procedure titled, Minimum Data Set (MDS) Assessments, dated October 20, 2021, indicated, . Quarterly Assessment (stated mandated subset or MPAF) must be completed every 92 days by the MDS coordinator or designee . A review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023, page 2-35, indicated The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident ' s status between comprehensive assessments to ensure critical indicators of gradual change in a resident ' s status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type.

Based on observation, interview, and record review, the facility failed to ensure accurate records of controlled medications (narcotic medications that are controlled by the government because it may be abused or cause addiction) were being maintained in accordance with their own policy and procedure for one of eight medication carts (room [ROOM NUMBER] medication cart). This failure had the potential for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by the staff in a highly vulnerable population of 49 residents. Findings: During a concurrent observation and interview, on January 11, 2024, at 5:50 AM, with a License Vocational Nurse (LVN 2), room [ROOM NUMBER]'s medication cart was inspected. LVN 2 stated Controlled Substance Inventory Count (CSIC) log is a form used by the facility to verify counting of controlled drugs at the change of every shift by oncoming and off going licensed staff. LVN 2 stated two nurses count the narcotics at the end and beginning of each shift, and both nurses must sign in the log. During a review of the CISC log, dated January 10, 2024, it indicated the following missing information and signature: 1. Clonazepam (used to prevent and control seizures) 2 MG (milligram - unit of measurements) tab (tablet): missing date, time, and signatures of day shift nurse and night shift nurse. 2. Valtoco (used to treat seizures) 15 MG nasal spray: missing time and signature of night shift nurse. 3. Valtoco 10 MG nasal spray: missing, date, time, and signatures of day shift nurse and night shift nurse. 4. Diazepam (used to treat anxiety, muscle spasms, and seizures) 2 MG tab: missing, date, time, and signatures for day shift nurse and night shift nurse. During a concurrent interview and review of CISC log on January 11, 2024, at 5:55 AM, with LVN 2, LVN 2 reviewed and confirmed the missing signatures, date, and time on the CISC log. LVN 2 stated, We [licensed staff] count but we forgot to sign. We both must sign. During a concurrent interview and record review, on January 12, 2024, at 9:42 AM, with Chief Nursing Officer (CNO) reviewed and acknowledged the facility's policy and procedure (P&P) titled, Controlled Substance Management-Nursing, dated June 25, 2009, which indicated, Accountability: At the change of each shift, both the licensed nurse leaving the shift and the nurse coming on duty must verify the count of controlled substances documented in both Controlled Substances Count sheets 3019-2 (SA) and 3019-6 (H). This is referred to as 'End-Of-Shift' or 'EOS' count in 3019-6(H). The CNO stated the two licensed staff nurses are required to count, sign the log at change of each shift.

Based on observation, interview, and record review, the facility failed to ensure correct medication administration technique was followed by one of the three sampled licensed staff (Registered Nurse [RN2]) when an extra dose of a Heparin flush (solution used for maintenance of patency of intravenous [IV-within vein] line was not properly wasted prior to administration Resident 24. This failure had a potential for medication error (observed or identified preparation or administration of medications which is not in accordance with the prescriber's order; manufacturer's specifications or accepted professional standards) which may lead to harm for Resident 24. Findings: During a review of Resident 24's clinical record, the face sheet indicated Resident 24 was admitted to the facility on [DATE] with diagnoses which included central line-associated bloodstream infection (CLABSI- primary bloodstream infection that develops in a patient with a central venous line [made of a long, thin, flexible tube that enters your body through a vein; travels through one or more veins until the tip reaches the large vein that empties into your heart] in place within the 48-hour period before onset of the bloodstream infection that is not related to infection at another site), and severe intellectual disability (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills). During a review of Resident 24's Physician's Order, dated September 3, 2022, it indicated Resident 24 had an order to received care for his central venous line, and to receive Heparin 10 units/ml [milliliter-unit of measure] NaCl [Sodium Chloride] 0.9% intravenous [IV] solution) 30 units, IV push, q[every] 12 hr; PRN [pro re nata/as needed]. During an observation on January 20, 2024, at 11:45 AM, at Resident 24's room, Resident 24 was lying in bed. Resident 24's central venous line was located at his right upper chest. During a concurrent observation and interview, with RN 2, on January 10, 2024, at 12:00 PM, RN 2 administered Heparin flush to Resident 24. RN 2 pushed 30 units/3ml and left the 20 units/2ml in the syringe. RN 2 did not waste the excess dose prior to administering the flush. RN 2 I usually waste it after administering the medication. During an interview with the Chief Nursing Officer (CNO), on January 11, 2024, at 1:35 PM, the CNO stated staff must waste the excess dose prior to giving the medication. The CNO further stated staff needed to be educated more regarding standard of practice and competency. When asked for a copy of facility policy regarding heparin flush and wasting medication prior to administration the CNO stated they do not have one. During an interview with the Director of Staff Education (DOE), on January 11, 2024, at 1:50 PM, the DOE stated, It was wrong, she [RN 2] should have wasted the excess medicine prior to giving the heparin flush. The DOE stated it can cause potential error and harm.

Based on interview and record review, the facility failed to ensure that 1 of 3 sampled residents (Resident A) was provided the necessary care and services, when the resident had a change in condition as evidenced by fluctuating vital signs on [DATE], and 5, 2014. Also, the licensed staff failed to notify the physician of Resident A's fluctuating vital signs on [DATE] and [DATE]. This failure resulted in Resident A being found unresponsive, with no respirations (no breathing) on [DATE] at 5:59 PM. Resident A was transported to the acute care hospital emergency department on the same day ([DATE]) at 6:34 PM, and the resident was pronounced dead at 7:02 PM. Findings: During a review of Resident A's clinical record, it noted that the resident was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. It further noted to attempt resuscitation/ Cardiopulmonary resuscitation (CPR, an emergency procedure that is performed on people who are suffering from [MEDICAL CONDITION], it includes rescue breathing and chest compressions). A review of the "Antibiotic Order," completed on [DATE], by the physician, noted that Resident A was suspected of having pneumonia (infection of the lungs). A review of a physician admission evaluation for Resident A, completed on [DATE], noted the following baseline (first set of) vital signs: (temperature, heart rate, respiration and blood pressure): A temperature of 97.4 degree Fahrenheit (F) axillary (under arm pit - normal range (NR) for axillary T was 97.6 F), the Pulse/Heart rate (HR) was 129 (NR was 60 -100), the Respirations (R) were 25 (NR was ,[DATE]), the blood pressure (B/P) was ,[DATE] (NR was ,[DATE]). On [DATE] at 12:00 PM, a concurrent interview and record review of Resident A's "Resident Care Flowsheet," (a flowsheet contained the licensed staff documentation of vital signs, physical assessment, equipment, treatment, intake and output and short term care planning issues) for the day shift of [DATE] and 5, 2014, was conducted with Licensed Vocational Nurse (LVN 1). LVN 1 was the licensed nurse assigned to provide direct nursing care for Resident A on [DATE] and 5, 2014. Resident A's "Resident Care Flowsheet" dated [DATE], showed the following: a. At 11:25 AM, Resident A's HR was 159 and the respirations were 40. The resident was suctioned and staff collected large pale yellow mucous (usually slimy clear fluid that lubricates the respiratory track) from the trach. Resident A was stable with no changes. There was no documentation that LVN 1 acknowledged the resident's increased heart rate or respirations. In addition, there was no documented evidence that the physician was notified of Resident A's increased heart rate and respirations. b. At 12:30 PM, the HR was 183 and the respirations were 64. There was no documented evidence that an nursing assessment was completed or that LVN 1 acknowledged Resident A's increased heart rate and respiration. In addition, there was no documented evidence that the physician was notified of the significant increase in Resident A's heart rate and respirations. c. At 2:00 PM, on [DATE], Resident A's HR was 114 and the respirations were 43, the Temperature was 99.8 F (axillary) and the B/P was ,[DATE]. There was no documented evidence that a nursing assessment was completed or that the physician was notified of Resident A's increased respirations and the elevated temperature. d. At 3:00 PM, Resident A's HR was 132 and the respirations were 47. Facility staff suctioned thick yellow mucous from the resident's trach. There was no documented evidence that LVN 1 acknowledged the resident's increased respirations and heart rate or that the physician was notified of Resident A's increase heart rate, increased respirations, or the thick yellow secretions. e. At 4:40 PM, Resident A's HR was 160 and the respirations were 40. There was no documented evidence that a nursing assessment was completed, that LVN 1 acknowledged the resident increased heart rate and respirations or that the physician was notified of the significant increase in Resident A's heart rate and the increased respirations. On [DATE] from 6:30 PM through [DATE] at 6:00 AM, Resident A's "Resident Care Assessment," noted the following: a. At 6:30 PM, Resident A's temperature was 99.4, HR was 130, respirations were 28, B/P was ,[DATE]. The licensed nurses' assessment noted that Resident A had no signs and symptoms of distress. b. Between 7:30 PM and 3:30 AM, there were eight (8) legible documented entries that noted the HR was between 87 and 118 (normal HR for Resident A). The were illegible documented entries for the HR at 4:10 AM and 6:00 AM. There were 11 documented entries that noted that the resident's respirations were between 20 and 32. On [DATE], Resident A's "Resident Care Assessment," noted the following: a. At 6:50 AM, Resident A's temperature was 98.2, HR was 110, respirations were 60 and B/P was ,[DATE]. The licensed nurses' assessment noted that Resident A was asleep and stable with no mention of the increased respirations. There was no documented evidence that the physician was notified of Resident A's increased respirations of 60 breaths per minute. b. At 8:05 AM, the licensed nurse documentation indicated that Resident A's HR was 173, but no respirations were documented. Resident A was awake with increased heart rate (actual HR not documented in the narrative), some agitation and was moving her extremities (arms and legs) all around the bed. There was no documented evidence that the physician was notified of Resident A's significant increase in heart rate at this time. c. At 10:00 AM, the resident's HR was 143 and the respirations were 64. There was no documented evidence that a nursing assessment was completed, the licensed nurse acknowledged the increased heart rate and respirations and/or the physician was notified of Resident A's increased heart rate and significant increase in respirations. d. At 11:10 AM, Resident A's HR was 135 and the respirations were 33. There was no documented evidence that a nursing assessment was completed on Resident A or that the physician was notified of the increased heart rate. e. At 12:20 PM, the resident temperature was 99.4 F axillary, the HR was 138, respirations were 52 and B/P was ,[DATE]. LVN 1 documented that Resident A had a low grade temperature (normal axillary temperature 97.6 F). Cooling measures were initiated and a blanket was removed off of the resident. The resident continued to move around in the bed. The staff tried to calm Resident A by repositioning and distracting the resident. There was no documented evidence that the physician was notified of the significant increase in respirations or the increased HR. In addition, there was no documented evidence that LVN 1 acknowledged the increased respirations or elevated heart rate. f. At 1:30 PM, Resident A's HR was 162 and no respirations were documented. LVN 1 stated when HR was recorded without respirations because the apnea monitor did not display the respirations at that time. There was no documented evidence that a nursing assessment was completed or that the physician was notified of the significant increase in heart rate. In addition, there was no documentation to indicate that the facility staff acknowledged the resident's increased heart rate. g. At 2:30 PM, Resident A's HR was 168 and no respirations were documented. Licensed nurse's documentation noted that the resident remained stable but irritable and that the charge nurse was notified of staff inability to comfort Resident A. There was no documented evidence that the physician was notified of Resident A's increased heart rate or to inform the physician that the staff was unable to comfort the resident. h. At 3:10 PM, LVN 1 documented that [MEDICATION NAME] (a medication used to treat anxiety disorders and allergic skin condition) was administered to Resident A for itching. i. At 3:20 PM, documentation noted that Resident A had an axillary temperature of 99.8 F, a HR of 97 and the Respirations were 45. There was no documented evidence that a nursing assessment of Resident A's was completed at this time or that cooling measures were initiated for Resident A increase temperature. There was also no documented evidence that the physician was notified of increase temperature and respirations. j. At 4:30 PM, the resident's HR was 190 and no respirations were documented. There was no documented evidence that a nursing assessment was completed or that the physician was notified of the significant increase in heart rate for Resident A. In addition, there was no documented evidence that staff acknowledged the resident's increased heart rate or attempted measures to decrease the heart rate. k. At 5:00 PM, Resident A's HR was 138 and the respirations were 42. LVN 1 documented that the [MEDICATION NAME] was ineffective and that Tylenol (medication used to treat mild to moderate pain) was administered for pain. There was no documented evidence that the physician was notified of the ineffectiveness of the [MEDICATION NAME], the elevated heart rate or the respirations. l. At 5:40 PM, Resident A's HR was 173 and the respirations were 66. There was no documented evidence that a nursing assessment was completed for Resident A or that the physician was notified of the significant increase in heart rate and respirations. In addition, there was no documented evidence that LVN 1 acknowledged the resident increased heart rate or the increased respirations, notified the Registered Nurse Supervisor or alerted the STAT Team (a medical emergency response team that provides a means for rapid and timely intervention in the event of a developing medical emergency) to assess Resident A. m. At 5:59 PM, LVN 1 documented that a Certified Nursing Assistant (CNA 1) informed her (LVN 1) that Resident A, "Appeared different, she (CNA 1) was having a problem reading the apnea monitor (a medical equipment that records heart rate and breathing pattern, and alarms when the heart rate slows down or when breathing stop for a period of time). Resident A was lying still, with dusky (bluish color). The STAT Team was called to bedside." LVN 1 documented that she started bagging (a manual bag valve mask used to deliver breaths manually when a patient is unable to breathe on their own) Resident A. 911 (emergency response) was called. During an interview on [DATE] at 12:00 PM, with LVN 1, she was asked if she knew what Resident A's baseline vital signs were. LVN 1 stated that she was not sure what Resident A's baseline vital signs were. LVN 1 was asked to explain Resident A's heart rate of 159 and respiration of 40 that was documented on [DATE] at 11:25 AM. LVN 1 stated that she recorded the numbers off of the apnea monitor. LVN 1 was then asked to explain why on [DATE], at 12:30 PM when Resident A's HR was 183 and the R were 64, why there was no documented evidence that an assessment was completed for the resident, or the physician was not notified of the significant increased heart rate and respirations. LVN 1 stated that the vital signs were not normal but if the resident was frailing (moving arms and legs uncontrollable) the vital signs would have fluctuated. During the same interview, LVN 1 was asked if she saw Resident A's increased heart rate and respirations as a problem, LVN 1 stated that she did not see it as a problem because the resident had been agitated on [DATE], and [DATE]. LVN 1 also stated that on [DATE], she was unable to comfort the resident. When asked if the physician was notified of Resident A's change of condition - fluctuating heart rate, respirations and increased agitation, LVN 1 responded, "No." LVN 1 further stated that the resident had been sick, was being treated with antibiotics for pneumonia starting [DATE] and therefore did not see the need to report/notify the physician. During the same interview, LVN 1 was asked why heart rate were documented without respirations. LVN 1 stated that when heart rate were documented without respirations, the apnea monitor did not display respirations. LVN 1 stated that she would reposition the patches because the resident was always trying to take the patches (leads connected to the apnea machine) off. LVN 1 also stated, "Resident A needed more suctioning due to increased secretions but respiratory wise did not seem too much out of normal. She was more irritable than normal." LVN 1 stated that she felt that the apnea monitor was picking up the resident's movement because the resident was not exhibiting distress at the time. LVN 1 was asked about Resident A's heart rate of 173 and respirations of 66 on [DATE], at 5:40 PM, when there was no documented nursing assessment. LVN 1 stated that the monitor was picking up the resident's movement, when the resident was pulling at everything but was not exhibiting distress. LVN 1 stated that the CNA informed her on [DATE], at 5:59 PM (19 minutes after Resident A's HR was 173 and the respirations were 66), that Resident A's apnea monitor was alarming with no reading and that the resident's color had changed. LVN 1 stated that when she arrived at Resident A's bedside, the resident was lying still and she started bagging the resident while the "STAT" team was called. A review of Resident A's hospital's emergency department (ED) medical record noted the resident arrived in the ED on [DATE], at 6:34 PM (2 hours after the facility staff documented the resident's heart rate of 190 and 35 minutes after the staff noticed that the resident's color had changed and the resident was not breathing). It also noted that there were multiple attempts of CPR (Cardiopulmonary resuscitation, an emergency procedure that is performed on people who are suffering from [MEDICAL CONDITION], it includes rescue breathing and chest compressions) made by the paramedics in route to the hospital. On arrival to the emergency department, the resident presented in asytole (absent of heart beat), the rectal temperature was 106.8 F (normal rectal T =100.8 F) and glucose (sugar concentration in blood and necessary for brain function) was 53 (normal range 70 -185 mg/dl milligrams/deciliters). The ED staff continued to perform CPR). The cardiac ultrasound showed no positive activity. CPR continued for 4 rounds without success and Resident A was pronounced dead at 7:02 PM on [DATE]. On [DATE], at 11:05 AM, a concurrent interview and record review of the "Resident Care Flowsheet," dated [DATE], was conducted with Registered Nurse (RN 1), the day shift supervisor on [DATE]. RN 1 stated that she was aware of Resident A's respiratory status the morning of [DATE], but was not sure of the resident's fluctuating heart rate and respirations. RN 1 stated that the resident was sick, active and moving around. RN 1 further stated that she did not notify the physician of Resident A's fluctuating HR and Respirations during the day shift on [DATE], or specifically on [DATE], at 12:30 PM when Resident A's HR was 183 and Respirations were 64. On [DATE], at 11:22 AM, a concurrent interview and review of the "Resident Care Flowsheet," dated [DATE], was conducted with RN 2, the day shift supervisor on [DATE]. RN 2 stated she was present on [DATE] at 5:59 PM when Resident A was found unresponsive. RN 2 stated that the physician was not notified of Resident A's significant and fluctuating heart rate, respirations and agitation on [DATE], during the day shift. RN 2 did not respond when asked if the fluctuating heart and respirations were normal for Resident A, for example, a heart rate of 173 and 190 and respirations of 60 or 66. RN 2 was asked when should staff call the physician and STAT Team. RN 2 responded, "If resident is in distress." During a review of the facility policy and procedure titled, "STAT Response Team", Policy: 2140- SA (Sub Acute), effective February 12, 2014, it noted, "The organization shall establish a Medical Emergency Response Team that will be available to health care staff to improve patient outcomes by providing a means for rapid and timely intervention in the event of a developing medical emergency." During a review of the physician documentation in Resident A's clinical record dated [DATE] at 3:00 PM, it noted, "I evaluated (resident) on [DATE] ([DATE]) and initiated orders as seen in her chart (included [MEDICATION NAME]-an antibiotic to treat pneumonia) ...I was not contacted regarding any changes in her clinical status until [DATE] ([DATE]) at 6:33 PM." (After Resident A was found unresponsive). On [DATE], at 11:45 PM, a concurrent interview and review of Resident A's "Resident Care Flowsheet", completed on the day shift on [DATE], and [DATE], was conducted with RN 3, the nurse manager for the unit. RN 3 stated that Resident A was in constant motion, very active but she was not sure if the fluctuation in the vital signs were caused by the resident's movement. When asked when would you call the STAT Team, RN 3 stated, "Will not call the STAT Team for a heart rate of 173 or respirations of 66 but can call STAT Team right away if things look uncomfortable. I knew she was not feeling well, was being treated, she was not crying or moaning. RN 3 was asked if a heart rate of 173 and respirations of 66 were not cause for alarm or notification of the physician. RN 3 stated, "you did not know the resident." The facility's policy and procedure for assessment and notification of the physician for change in condition were requested. During a review on [DATE], of the facility policy and procedure titled, "Notification of Change in Patient Condition", Policy: 2711-H, effective [DATE], it noted: "Significant changes in patient condition are appropriately reported. Changes include bur are not limited to: changes in physical, behavioral, or psychosocial condition, accidents, injuries, and changes in medical treatment ...Charge nurses, physicians,...will be notified as soon as possible of changes in patient's condition." During a telephone interview on [DATE], at 4:00 PM, with CNA 1, who was assigned to provide care for Resident A and found the resident unresponsive on [DATE], she stated that this was her first time assigned to care for the resident. CNA 1 stated that Resident A had been agitated, with high vital signs throughout the shift and that LVN 1 was aware of them. CNA 1 stated that around 5:30 PM on [DATE], while making her final round, she was in Resident A's room and assisting another resident when she heard Resident A's apnea monitor alarming. She went to Resident A's bed and replaced the patches on her chest but the numbers on the apnea machine were jumping high and low. Resident A was still, the palm of her hand looked gray, while the monitor was alarming. CNA 1 stated that she ran and got the charge nurse (LVN 1), who was in another room. On [DATE] at 4:30 PM, a concurrent interview and review of Resident A's "Respiratory Care Flowsheet," completed by the Respiratory Therapists (RT) from [DATE] through [DATE], was conducted with the Respiratory Manager (RM): On [DATE], Resident A's "Respiratory Care Flowsheet," the following: a. At 7:20 AM, the pre treatment heart rate was 137 and post heart rate was 110. The pre treatment respirations were 26 and the post were 26. b. At 11:05 AM, the pre treatment heart rate was 138 and post heart rate was 192. The pre treatment respirations were 42 and the post were 40. c. At 3:55 PM, the pre treatment heart rate was 158 and post heart rate was 178. The pre treatment respirations were 48 and the post were 45. d. At 8:05 PM, the pre treatment heart rate was 157 and post heart rate was 158. The pre treatment respirations were 55 and the post were 58. On [DATE], Resident A's "Respiratory Care Flowsheet," noted the following: At 4:00 PM, the pre treatment heart rate was 190 and post heart rate was 180. The pre treatment respirations were 36 and the post were 34. The RT documented that the resident had increased agitation and heart rate. During the same interview, the Respiratory Manager (RM) was asked if the heart rate and respirations were normal when compared to other vitals. The RM stated that they were high, especially a heart rate of 190. The RM was asked the expectation when the vital signs were high or fluctuating. She responded that respiratory and nursing staff should do an assessment of the resident and call the physician. The RM was asked why the apnea monitor did not display respirations at times according to LVN 1. The RM stated that if the patches were not positioned properly on the chest or back, respirations will not be displayed and staff should repositioned the patches. On [DATE] at 4:40 PM, a concurrent interview and review of Resident A's "Resident Care Flowsheet," completed by the licensed nurse for [DATE] and [DATE], was conducted with the Director of Patient Care Services (DPCS): On [DATE], Resident A's "Resident Care Flowsheet," noted the following: At 12:30 PM, the heart rate was 183 and the respirations were 64. There was no documented nursing assessment. On [DATE], Resident A's "Resident Care Flowsheet," noted the following: a. At 5:00 PM, the heart rate was 138 and the respirations were 42. Tylenol was administered for pain. b. At 5:40 PM, Resident A's heart rate was 173 and the respirations were 66. There was no documented evidence that a nursing assessment was completed. During the same interview with the DPCS, she acknowledged that Resident A's vital signs had been fluctuating especially on [DATE] and [DATE]. The DPCS stated that the licensed nurse administered pain medication on [DATE] at 5:00 PM and was waiting to evaluate the effectiveness of the pain medication. On further review it was noted that on [DATE], at 5:40 PM, the heart rate and the respirations were significantly higher than 40 minutes prior to administration of pain medication and there was no documented nursing assessment of the resident. At 5:59 PM, 19 minutes later, after the significant high heart rate and respirations, Resident A was found unresponsive and not breathing. The DPCS further stated that when the heart rate and respirations were high, the nursing staff should have completed a blood pressure and temperature to complete the vital signs, complete a head to toe assessment of the resident and report the findings to the physician for interventions. The DPCS could not locate protocols or nursing policies and procedures directing staff on parameters for abnormal vital signs or directing staff on manual counting of respirations or listening to the heart rate with a stethoscope to verify that the heart rate and respirations displayed on the apnea monitor were accurate. A review of the facility policy and procedure titled, "Pain Assessment and Management," effective [DATE], noted: "The nursing staff shall maintain a record of vital signs and functioning status of the patient and assess the effects of pain management on the patient's status." "Patients shall be continually monitored for adverse reactions to pain management." "The physician shall be notified of any adverse reactions and the pain management plan shall be revised to better suit the needs of the patient." On [DATE] at 1:50 PM, an interview was conducted with Physician 1, Resident A's physician on [DATE] and 5, 2014 (dates of change of condition). Physician 1 stated she was not notified of Resident A's change of condition (significant fluctuating heart rate, respirations and increased agitation) until [DATE], around 6:30 PM, when the resident was in route to the acute care hospital emergency room . Physician 1 stated she should have been notified sooner of the resident's change in condition so she could have had the opportunity to provide treatment for [REDACTED]. acceptable because of the patient's pain and contractures. When asked about respirations of 66, she stated that number was not acceptable. Physician 1 was asked what should have been done. She stated the licensed nurse should have notified the charge nurse (Registered Nurse) of the discrepancy in the vital signs, the charge nurse should have assessed the resident and notify her.